Advances in Clinical and Medical Research

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Research Article | Khalil NS, et al. Adv Clin Med Res 2021, 2(1)-16.

Advances in Clinical and Medical Research Genesis-ACMR-2(1)-16

Volume 2 | Issue 1 Open Access

Effects of ABCDE Bundle Implementation on

Reduction of Delirium among Mechanically

Ventilated Patients at Damietta Hospital,

Egypt

Khalil NS1*

, El-Kady EM2, Abdel-kaderFA

3, and EL-shafey MM

3

1Department of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Egypt

2Department of Critical Care and Emergency Nursing, Faculty of Nursing, Mansoura University, Egypt

3Department of pulmonary and critical Medicine, Faculty of Medicine, Mansoura University, Egypt

*Corresponding author: Nahla Shaaban Khalil, Department of Critical Care and Emergency Nursing, Faculty of

Nursing, Cairo University, Egypt

Citation: Khalil NS, El-Kady EM, Abdel-kaderFA, and

EL-shafey MM. (2021) Effects of ABCDE Bundle

Implementation on Reduction of Delirium among

Mechanically Ventilated Patients at Damietta Hospital,

Egypt. Adv Clin Med Res. 2(1):1-16.

Received: January 16, 2021 | Published: February 11,

2021

Copyright©

2021 by Khalil NS. All rights reserved.

This is an open access article distributed under the

terms of the Creative Commons Attribution License,

which permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Abstract Background: One of the principal complications in intensive care unit particularly those connected to mechanical

ventilation is delirium. Delirium. It is associated with increased mortality, prolonged mechanical ventilation, and

prolonged hospital length of stay (LOS). The ABCDE is a bundle intervention that stands for awakening, breathing

coordination, delirium monitoring/management, and early exercise/mobility bundle that has been proposed as a

multi-component intervention to reduce the incidence of delirium.

Aim of the study: This study aimed to evaluate the effect of implementing the ABCDE bundle on the reduction of

delirium among mechanically ventilated patients at Damietta hospital.

Material and Methods: A quasi-experimental pre/post-intervention design was used to conduct this study. A

purposive sample of 65 adult male and female mechanically ventilated patients aged between 18 and 60 years was

recruited. Sedation and Delirium instruments measures were utilized in data collection.

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Introduction

Delirium is a frequent and serious problem in the intensive care unit (ICU). It is common in the early

stages of hospitalization for a variety of acute and chronic diseases [1]. Delirium in ICU affects 60 to 80%

of patients receiving mechanical ventilation and 20 to 50% of patients who are not receiving mechanical

ventilation [2]. It is associated with increased mortality, prolonged mechanical ventilation, and

prolonged hospital length of stay (LOS) [3]. Moreover, its consequences can be prevented by proper

assessment, diagnosis and management [4].

Delirium is a dysfunction that occurs due to various pathophysiological factors such as the inflammatory

reaction of the brain to injury, hormonal affection, and alterations in neurotransmission connections

[5]. It’s categorized into three subtypes: hyperactive, hypoactive, and mixed type. Hyperactive delirium

is characterized by aggression, agitation delusion, hallucination, and psychomotor

hyperactivity. Hypoactive delirious patients may show decreased attention, lethargy, slowed

psychomotor activities and reduced responsiveness. Patients with mixed type delirium fluctuate

between hyperactive and hypoactive delirium [6].

The Society of Critical Care Medicine for the management of pain, agitation, and delirium (SCCM

PAD) guidelines 2013, in adult patients in the ICU, described bundle of interventions to be adopted in

the care of patients connected to mechanical a ventilator is known as “ABCDE” that involve

awakening, breathing trial coordination with suitable sedation, management of delirium, and

early mobility [7]. The ABCDE bundle principally depends upon three rules improving interaction health

team members in critical care settings, providing standard care, and decreasing connection

to mechanical ventilation and over sedation that result in delirium [8].

ABCDE bundle is a group of practices that based on evidence-based guidelines when practices totally

have been verified to promote patient outcomes. Those bundles are utilized in critical care units. The

use of bundles may be similarly beneficial for developing patient-centered protocols for preventing and

treating PAD in critically ill patients [6].

Result: significant differences were found in delirium scores among the studied patients (x2= 52.52; p-

value=0.001). So, the mechanically ventilated patients who exposed to the implementation of the ABCDE bundle

were experienced fewer delirium signs than before the ABCDE bundle implementation.

Conclusion: It can be concluded ABCDE bundle implementation reduced the occurrence of delirium among

mechanically ventilated patients.

Recommendations: ABCDE bundle should be implemented in mechanically ventilated patients.

Keywords ABCDE bundle; Mechanically ventilated patients; Critically Ill Patients

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The aim of the study

The aim of the study is to evaluate the effect of implementing the ABCDE bundle on the reduction of

delirium into everyday practice for mechanically ventilated patients at Damietta hospital in Egypt.

Research hypothesis

Mechanically ventilated patients who are exposed to the implementation of the ABCDE bundle will

experience fewer delirium signs than those who received routine care.

Research design

A quasi-experimental research design was chosen to demonstrate causality between intervention and

outcome. It is an experimental study used to appraise the causal- effect of an experiment on the

population without randomization. It permits the researcher to control the intervention or

experimentation but utilizing some norms other than randomization. In some cases, the researcher may

have control over an assignment to treatment [9-10].

Setting

This study was conducted in the intensive care units at Damietta Chest Disease Hospital.

Subjects

A purposive sample of 65 adult male and female mechanically ventilated patients aged between 18 and

60 years were included. The exclusion criteria included Patients with congestive heart failure, sepsis,

prolonged restraints and immobility, seizures, and head trauma [11-12].

Sample Size Calculation With alpha error 5% and study power 80% with the expected incidence of delirium in the intervention

arm =40% and 80% in the non-intervention arm, then the sample size = 60 in each group. Add 10% (5

cases for each group to compensate for defaulters) then the final sample size = 65 in pre-intervention

and post-intervention groups.

Tools of data collection

Instrument 1: patients’ demographic & Health Relevant Data

This tool was developed by the researcher; it included patient's demographic data (name, age, gender,

diagnosis, and date of admission, past medical history, level of consciousness, mobility status,

medications, analgesics, and sedation).

Instrument 2: Sedation assessment (Riker Sedation-Agitation Scale (SAS)

That tool was adopted from [13]. It was used to assess sedation levels. Riker Sedation Agitation Scale

(SAS) was the first scale proven to be reliable and valid in critically ill adults. SAS scores a patient’s level

of consciousness and agitation from 7 points list describing patient behavior. (SAS Target Sedation = 3 to

4). Riker Sedation Agitation Scale (SAS) contains 7 points, (7) Dangerous Agitation, (6) Very Agitated, (5)

https://en.wikipedia.org/wiki/Causal

https://en.wikipedia.org/wiki/Random_assignment

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Agitated, (4) Calm and Cooperative, (3) Sedated, (2) Very Sedated, (1) Unarousable, it is used every 4

hours after the patient's connection to mechanical ventilation and lasts for three days for both groups.

Tool III: Delirium assessment (Intensive Care Delirium Screening Checklist (ICDSC)

The researcher assessed the patient's delirium status by using the Intensive Care Delirium Screening

Checklist (ICDSC). It was adopted from [14], to assess the level of consciousness, inattention,

disorientation, hallucinations, psychomotor agitation, speech/ mood disturbance, sleep disturbance, and

fluctuation of symptoms. The researcher used this tool every 12 hours after the patient waked up and

lasted for three days before and after implementation of the ABCDE bundle. The ICDSC contains 8 items,

each item is scored as absent or present (0 or 1) and summed, A score (>4) indicates (delirium), while (0-

3) indicates (no delirium).

Validity and Reliability of the instruments

The tools were tested for content-related validity by a panel of 5 experts in the Critical Care and

Emergency Nursing Department, and Intensive Care Medicine Department at Mansoura and Cairo

Universities. A reliability test was applied by the researcher for testing the internal consistency of the

developed instrument; the Delirium Screening Checklist. The reliability was 0.876.

The procedure of Data collection

Permission to conduct the study was obtained from the hospital research committee after an

explanation of the aim and nature of the study. The patients or their families were contacted to explain

the nature and purpose of the study. Then, informed consent was obtained from them in case of

unconscious patients. After that, the researcher collected the patients' demographic & health-relevant

data. Later, the researcher evaluated the patient's sedation level utilizing Riker Sedation- Agitation Scale

(SAS). Finally, the researcher assessed the delirium status by using the Intensive Care Delirium Screening

Checklist (ICDSC).

The researcher assessed sedation level by using the Riker Sedation-Agitation Scale trough observing the

patient's consciousness and recorded the results, if the patient awoke and able to follow three or four

simple commands, or was agitated, the researcher informed the respiratory therapist and initiate to

wean the patient from the mechanical ventilation, but if the patient unarousable or much sedated, the

researcher continued sedatives under medical supervision and re-assed the patient in the next 24 hours.

When the patient achieved a score (3-4) in the Riker Sedation Agitation Scale (SAS), and able to follow

three or four simple commands, the researcher informed the respiratory therapist and started to

liberate the patient from the mechanical ventilator through (wake up and breath protocol).

Implementation of ABCDE bundle

Awakening and Breathing Coordination Trials (ABCs)

It was adopted from [15]. This protocol included Awakening and Breathing Coordination Trials (ABCs).

The researcher was responsible for performing Spontaneous Awakening Trials (SATs), and the

Respiratory Therapist was responsible for performing the Spontaneous Breathing Trials (SBTs) for every

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mechanically ventilated patient by determining if a mechanically ventilated patient is ready to breathe

on his\her own through.(Wake UP and Breathe Protocol).

Early mobility protocol

This protocol was selected from [16]. It encouraged the initiation of early mobility and increase

ambulation of patients. The physical therapist and the researcher applied this protocol at least once per

day and lasted for three days. This protocol had four levels of activity. The first level of activity was a

passive range of motion performed by the mobility team nursing assistants. Active resistance exercises'

were initiated in the second level and later; the patient was being placed in the upright position three

times daily. Activity gradually increased in the third and fourth levels from sitting on the edge of the bed

and then actively transferring to a chair out of the bed.

Results Table 1 illustrates patients' demographic and health Relevant data. It revealed that almost two-thirds of

the patients aged 50 to 59 years old, and two-thirds of them were male. Regarding the past medical

history, 24.62% of the patients were suffering from COPD, and 15.38% were diagnosed with renal

failure. Moreover, in relation to the level of consciousness and mobility status, most of the patients

(86.15%) were conscious and nearly two-thirds of them (64.62%) were mobile. Regarding the use of

sedatives and opioids, nearly half (53.85%) of patients received sedatives, while Opioids were used by

one-third (30.77%). moreover, 15.38% were using antipsychotic drugs.

Variables No. % Mean ±SD

Age (years)

≤ 20 years 2 3.08% 12.50±16.26

21-29 years 1 1.54% 25

30-39 years 5 7.69% 10.20±6.61

40-49 years 7 10.77% 17.00±10.98

50-59 years 40 61.54% 37.80±16.39

≥ 60 years 10 15.38% 37.30±20.77

Mean ±SD 41.64±0.97

Gender

Male 39 60.00%

Female 26 40.00%

Past History

Respiratory

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COPD 16 24.62%

RF 10 15.38%

Cardiac

MI 8 12.31%

IHD 5 7.69%

AF 3 4.62%

Others

Myasthenia.

Gravis 2 3.08%

Carcinoma 4 6.15%

Stroke 8 12.31%

Hepatic 5 7.69%

Renal 4 6.15%

Level of

consciousness

Conscious 56 86.15%

Unconscious 9 13.85%

Mobility status

Mobile 42 64.62%

Immobile 7 10.77%

Need assistance 16 24.62%

Medication

Opioids 20 30.77%

Sedatives 35 53.85%

Antipsychotic

drugs 10 15.38%

Table 1: patients’ demographic and health relevant data.

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Patient’s behavior

according to SAS Score

1st

Day 2nd

Day 3rd

Day Chi-square

No. % No. % No. % c2 P-Value

Unarousable 1 1.54 4 6.15 4 6.15

89.57 .001⃰

Very sedated 7 10.77 1 1.54 2 3.08

Sedated 49 75.38 32 49.23 5 7.69

Calm and cooperative 5 7.69 27 41.54 54 83.08

Agitated 1 1.54 1 1.54 - -

Very agitated 2 3.08 - - - -

Mean ±SD 3.06 ±0.77 3.31 ±0.81 3.68 ±0.81

*Significance at P level ≤0.05

Table 2: Distribution of patient’s response utilizing Riker Sedation-Agitation Scale (SAS).

(Table 2) shows patients' response in Riker Sedation-Agitation Scale (SAS) evaluation. It revealed

significant differences in patients’ Riker Sedation -Agitation responses (x2= 89.57; P= .001). So; most of

the patients (83.08%) showed calm and cooperative behavior on the third day when compared to other

days. On the other hand, three fourth (75.38%) showed sedation on the first day. (Table 3) illustrates

the incidence of delirium in the studied patients before intervention. It showed that most patients were

delirious (87.69%).

Table 3: Frequency distribution of the incidence of delirium among the studied subjects Before ABCDE

implementation

Incidence of

Delirium

ICDSC

Score

Chi-square

N % P-Value

No 3 8 12.31

36.94 0.001⃰⃰⃰

Total 8 12.31

Yes

4 10 15.38

5 25 38.46

6 12 18.46

7 7 10.77

8 3 4.62

Total 57 87.69

Mean ±SD pre 3.76±1.35

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(Table 4) shows the distribution incidence of delirium among the studied patients after the intervention

through three days. It revealed that nearly half (55.38%) of the patients hadn’t any signs of delirium on

the first day. This ratio was changed to better on the second day that revealed (63.08%) of patients

were sub-syndromal delirium. On the other hand, on the third day, nearly three fourth of patients

(75.38%) had no signs of delirium. As well, a significant statistical difference among the means delirium

scores in the three days. So, the delirium scores decrease on the second day compared to the first and

third day.

Days Incidence of

Delirium

ICDSC

Score # No. %

Chi-square ANOVA

P-Value F P-Value

1st

Day

No

2 1 1.54

92.77 0.001⃰

5 0.001

3 35 53.85

Total 36 55.38

Yes

4 12 18.46

5 1 1.54

6 3 4.62

7 7 10.77

8 6 9.23

Total 29 44.62

Mean ±SD 4.23±1.80

2nd

Day

No

2 3 4.62

88.51 0.001⃰

3 38 58.46

Total 41 63.08

Yes

4 12 18.46

5 7 10.77

6 4 6.15

7 1 1.54

Total 24 36.92

Mean ±SD 3.60±1.06

3rd

Day

No

2 14 21.54

16.75 0.001⃰

3 35 53.85

Total 49 75.38

Yes

4 2 3.08

5 4 6.15

6 7 10.77

7 3 4.62

Total 16 24.62

Mean ±SD= 3.45±1.43

Table 4: Frequency distribution of the incidence of delirium among the studied subjects after the intervention

through three days.

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As can be seen from (Table 5), there is no significant differences among patients’ incidence of delirium

by their gender through three days.

Time Sex N Mean SD T-test

T DF P-value

1st

day Male 39 4.27 1.9

1.4 63 0.889 Female 26 4.19 1.67

2nd

day Male 30 3.56 1.14

0.333 63 0.74 Female 35 3.65 0.94

3rd

day Male 45 3.41 1.33

0.747 63 0.806 Female 20 3.5 1.58

Table 5: Comparison of mean delirium scores by their gender.

As can be seen from (Table 6) that age is positively correlated with the incidence of delirium. (R=0.32).

Variable Mean ±SD Correlation coefficient

r P-value

Age 56.80±3.526 0.32* 0.017

Delirium 3.64±1.56

Table 6: Correlation between patients’ age and delirium.

It’s apparent from (Table 7) that no significant differences were found among patients’ delirium scores

by their current diseases

Disease No. % Delirium

Mean±SD

COPD 16 24.62% 3.81±1.80

RF 10 15.38% 3.60±1.51

MI 8 12.31% 3.38±1.41

Stroke 8 12.31% 3.13±1.25

F=0.381; P=0.767

Table 7: Comparison of mean delirium scores by their current disease.

Discussion The present study aimed to evaluate the effect of implementing the ABCDE bundle on the reduction of

delirium among mechanically ventilated patients at Damietta hospital in Egypt. The current study

showed that nearly two-thirds of the patients their age ranged between 50 to 59 years old, male, and

had delirium. The possible explanation for this finding may have relevant to a decreased level of

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acetylcholine. So, acetylcholine is one of the major neurotransmitters involved in Reticular Activating

System (RAS) function that declines with age and triggering the occurrence of delirium in the elderly,

and anticholinergic agents tend to worsen the symptoms of delirium. This study finding is consistent

with [17]. Who studied the major risk factors of delirium among a vulnerable group of patients to

delirium.

The following studies [18-19] who revealed that age and male gender as the major demographic risk

factors for the development of delirium across a wide range of clinical settings for medical and surgical

patients. As well, [20-21] who studied Delirium and coma in mechanically ventilated patients in the

intensive care unit in Japan agreed with the fact that older age was associated with delirium. On the

other hand, the current findings were in contrast with [22] who studied young patients with trauma who

were victims of road accidents and urban violence with the mean age of 37 years old and found that

there was a predominantly young population, age was still a determining factor for the incidence of

delirium.

Concerning to mobility status of studied patients; our study showed that two-thirds of patients were

mobile. This phenomenon helped in the implementation of early mobility in the ABCDE bundle and

shortened the time spent in patients' connection to a mechanical ventilator. As a result, it decreased the

incidence of delirium and increased the rate of early ambulatory mobilization practice [23-24]. This

study finding is agreed with [25] who recommended the early mobilization of critically ill patients at the

earliest time to improve patient safety.

Regarding the medications being administered, the current study revealed that more than half of

patients received sedatives. On the other hand, patients who received opioids were less than one-third

of the studied patients. So, these medications have a detrimental effect and are risk factors for the

occurrence of delirium [26]. These results are in line with (27, 28) who showed that the use of ben-

zodiazepines like midazolam for critically ill patients favors the emergence of delirium, longer ICU stay,

and more dependence on the mechanical ventilator.

On the other hand, these findings are not matched with [29] who analyzed the use of dexmedetomidine

and propofol instead of benzodiazepines to sedate patients, which reduced the length of ICU stay and

MV duration. Moreover, the current study showed that more than one-tenth of the studied patients

received antipsychotic drugs. The same findings are agreed with the American Association of Critical-

Care Nurses (AACN) [30] who declared that all patients who received antipsychotics such as; haloperidol

or any of the atypical antipsychotics may develop delirium and recommended that these patients should

be routinely and systematically monitored for side effects. As well, [31] determined that the risk of

delirium can be lowered in surgical inpatients by the preventive use of antipsychotic drugs. However,

the use of antipsychotic medications did not result in a remarkable effect on the length of delirium and

duration of hospital stay. On the other side, [32] stated that utilization of psychotropic agents in

critically ill patients without a specific diagnosis might increase the duration of hospital stay and

mortality.

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Concerning the assessment of patients' sedation and agitation utilizing the Riker Sedation Agitation

Scale before and after ABCDE implementation in three days, the study findings revealed that more than

three-quarters of patients were sedated on the 1st day compared to the majority of patients who were

very calm and cooperative on the third day. This finding may have relevant to the recommendation of

the use of sedatives and early relief of pain to improve ICU delirium [33-34]. This practice was led to a

decreased need for using mechanical restraint devices, allowed for an early initiation of mobility

contributing to better clinical conditions of patients. Moreover, it reduced costs related to therapy and

the prevention of delirium. Similarly, these findings are agreed with [7] who confirmed a strong

association between delirium and exposure to sedatives.

On the other hand, [35] added that critical care clinicians frequently fail to recognize delirium in their

patients due to improper use of sedation which resulting in longer ICU and hospital stays, an increase in

mortality, and long-term cognitive impairments [36]. As well, the current finding is consistent with

another study done by [37] who studied sedation in patients with delirium and found a deeper level of

sedation in delirious patients than those without delirium and also after sedation interruption. This

finding clarified a fact that sedatives can persist in the body for a significant duration in critically ill

patients. Moreover, a Persistent Delirium was found to be at a deeper level of sedation at their 2-hour

assessment than those with Rapidly Reversible Delirium (RRD). So, over sedation played a significant role

in the negative outcomes seen in this population.

On the other hand, this finding is incongruent with [38] who demonstrated that patients were not only

continued \to remain moderately sedated for up to 2 hours despite the removal of sedative medications

but those at a deeper level of sedation had an increased incidence of delirium, irrespective of the

delirium screening instrument used. However, 20% and 32% of the patients in their study received

continuous and intermittent sedation with midazolam, respectively, which may have been responsible

for the delayed awakening trials.

Moreover, [39] who mentioned that dexmedetomidine was associated with the onset of delirium but

with fewer neurocognitive disorders than propofol. On the other hand, [40] have found that

dexmedetomidine sedation in contrast to propofol preserved or even improved cognitive function in

patients with decreased baseline cognition. The current finding was consistent with [41, 36, 23] who

applied the ABCDE bundle protocol and found that implementation of the bundle reduced the delirium

from 62.3% to 48.7%, as well as the length of stay on mechanical ventilation.

Summarily, [2] who studied the effect of ABCDE bundle implementation on the prevalence of delirium in

intensive care unit patients found that implementation of the ABCDE bundle decreased the prevalence

of delirium significantly from two fifths to one fifth and the mean number of days of delirium decreased

from three days to one day. As well, this finding is consistent with [42] who carried out the study in

patients in post-cardiac surgery through care delivered by nurses and their staff and found results

preventing delirium among patients in post-cardiac surgery in the intervention group and the

occurrence of delirium was lower in comparison with the group that did not receive it. On the other

hand, [43] who carried a study in a medical and surgical ICU where patients were called by the first

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names, informed about the place of hospitalization and the development of their clinical condition,

found that these interventions were considered to be protective against the occurrence of delirium. It is

worth noticing that these are simple interventions that help in preventing delirium and that nurses

should appraise and use these interventions in nursing care and encourage the staff to do it.

Concerning the correlation of delirium with their demographic characteristics, the current study found a

positive correlation between patients’ age, and the incidence of delirium, which approved that patient

who ages between 50 to 59 years, had a higher incidence of delirium as it was a risk factor for delirium

[44]. These results agreed with [3] who found that patients with a diagnosis of delirium were older. Also,

[45] who studied delirium in palliative care settings found that delirium is prevalent among old age

patients especially male patient [46-47] but contrasted with our study that showed that there was no

correlation found between patients' gender and incidence of delirium.

Also, [48] who studied the development of postoperative delirium in elderly patients undergoing

orthopedic surgery found that delirium incidence is higher in male patients and mentioned that male

gender is a risk factor for delirium. On the other hand, this finding is not agreed with [49] who studied

delirium prevalence, risk factors, and cognitive functions in elderly hip fracture cases under general and

spinal anesthesia and found no significant association between gender and delirium.

Moreover, our study finding revealed that nearly half of chronic obstructive pulmonary disease (COPD)

patients had a higher incidence of delirium. This finding may have relevant to systemic inflammation and

blood-oxygenation disorders and they are considered as a risk factor for delirium [50]. This finding is

consistent with [51] who studied the missing links of systemic inflammation and oxidative stress in the

relation between COPD and incidence of delirium.

Conclusion Based on the findings of the present study, there was a significant improvement of delirium after a

successful implementation of the elements of the ABCDE bundle that included spontaneous awakening

trials (SAT), spontaneous breathing trials (SBT), coordination of SAT and SBT, careful selection of

sedative, delirium assessment and prevention, and early mobility.

Recommendations Implementation of ABCDE bundle among mechanically ventilated patients.

Limitation of the Study The sample was drawn from one hospital in one geographical area in the Arab Republic of Egypt that

restricts the generalization of findings. Patients with Congestive heart failure, sepsis, prolonged restraint

use and immobility, withdrawal seizures, head trauma, and intracranial space-occupying lesions will be

excluded from this study.

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